Substance/Medication-Induced Depressive Disorder
DSM-5 Diagnostic Criteria A'''. A prominent and persistent disturbance in mood that predominates in the clinical picture and is characterized by depressed mood or markedly diminished interest or pleasure in all, or almost all, activities. '''B. There is evidence from the history, physical examination, or laboratory findings of both (1) and (2): # The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication. # The involved substance/medication is capable of producing the symptoms in Criterion A. C'''. The disturbance is not better explained by a depressive disorder that is not substance/medication-induced. Such evidence of an independent depressive disorder could include the following: * The symptoms preceded the onset of the substance/medication use. * The symptoms persist for a substantial period of time (e.g., about 1 month) after the cessation of acute withdrawal or severe intoxication. * There is other evidence suggesting the existence of an independent non-substance/medication-induced depressive disorder (e.g., a history of recurrent non-substance/medication-related episodes). '''D. The disturbance does not occur exclusively during the course of a delirium. E'''. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. '''Note: This diagnosis should be made instead of a diagnosis of substance intoxication or substance withdrawal only when the symptoms in Criterion A predominate in the clinical picture and when they are sufficiently severe to warrant clinical attention. Note: If a mild substance use disorder is comorbid with the substance-induced depressive disorder, the clinican should record "mild substance use disorder" before the substance-induced depressive disorder (e.g., mild cocaine use disorder with cocaine-induced depressive disorder"). If a moderate or severe substance use disorder is comorbid with the substance-induced depressive disorder, the clinician should record "moderate substance use disorder" or "severe substance use disorder," depending on the severity of the comorbid substance use disorder. If there is no comorbid substance use disorder, then the clinician should record only the substance-induced depressive disorder. Specify if: * With onset during intoxication: If criteria are met for intoxication with the substance and the symptoms develop during intoxication. * With onset during withdrawal: If criteria are met for withdrawal from the substance and the symptoms develop during, or shortly after, withdrawal. Recording Procedures The name of the substance/medication-induced depressive disorder begins with the specific substance (e.g., cocaine, dexamethasone) that is presumed to be causing the depressive symptoms. In cases in which a substance is judged to be an etiological factor but the specific class of substance is unknown, the category "unknown substance" should be used. When recording the name of the disorder, the comorbid substance use disorder (if any) is listed first, followed by the word "with," followed by the name of the substance-induced depressive disorder, followed by the specification on onset (i.e., onset during intoxication, onset during withdrawal). For example, in the case of depressive symptoms occurring during withdrawal in a man with a severe cocaine use disorder, the diagnosis is severe cocaine use disorder with cocaine-induced depressive disorder, with onset during withdrawal. A separate diagnosis of the comorbid severe cocaine use disorder is not given. If the substance-induced depressive disorder occurs without a comorbid substance use disorder (e.g., after a one-time heavy use of the substance), no accompanying substance use disorder is noted (e.g., phencyclidine-induced depressive disorder, with onset during intoxication). When more than one substance is judged to play a significant role in the development of depressive mood symptoms, each should be listed separately (e.g., severe methylphenidate use disorder with methylphenidate-induced depressive disorder, with onset during withdrawal; dexamethasone-induced depressive disorder, with onset during intoxication). Differential Diagnosis Substance intoxication and withdrawal Depressive symptoms occur commonly in substance intoxication and substance withdrawal, and the diagnosis of substance-specific intoxication or withdrawal will usually suffice to categorize the symptom presentation A diagnosis of substance-induced depressive disorder should be made instead of a diagnosis of substance intoxication or substance withdrawal when the mood symptoms are sufficiently severe to warrant independent clinical attention. For example, dysphoric mood is a characteristic feature of cocaine withdrawal. Substance/medication-induced depressive disorder should be diagnosed instead of cocaine withdrawal only if the mood disturbance is substantially more intense or longer lasting than what is usually encountered with cocaine withdrawal and is sufficiently severe to be a separate focus of attention and treatment. Primary depressive disorder A substance/medication-induced depressive disorder is distinguished from a primary depressive disorder by the fact that a substance is judged to be etiologically related to the symptoms. Depressive disorder due to another medical condition Because individuals with other medical conditions often take medications for these conditions, the clinician must consider the possibility that the mood symptoms are caused by the physiological consequences of the medical condition rather than the medication, in which case depressive disorder due to another medical condition is diagnosed. The history often provides the primary bases for such a judgement. At times, a change in the treatment for the other medical condition (e.g., medication substitution or discontinuation) may be needed to determine empirically whether the medication is the causative agent. If the clinician has ascertained that the disturbance is a function of both another medical condition and substance use or withdrawal, both diagnoses (i.e., depressive disorder due to another medical condition and substance/medication-induced depressive disorder) may be given. When there is insufficient evidence to determine whether the depressive symptoms are associated with substance (including a medication) ingestion or withdrawal or with another medical condition or are primary (i.e., not a function of either a substance or another medical condition), a diagnosis of other specified depressive disorder or unspecified depressive disorder would be indicated.